{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,5]],"date-time":"2026-05-05T00:19:53Z","timestamp":1777940393008,"version":"3.51.4"},"reference-count":24,"publisher":"SAGE Publications","issue":"4","license":[{"start":{"date-parts":[[2017,11,1]],"date-time":"2017-11-01T00:00:00Z","timestamp":1509494400000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/journals.sagepub.com\/page\/policies\/text-and-data-mining-license"}],"content-domain":{"domain":["journals.sagepub.com"],"crossmark-restriction":true},"short-container-title":["Policy, Politics, &amp; Nursing Practice"],"published-print":{"date-parts":[[2017,11]]},"abstract":"<jats:p>States that did not expand Medicaid under the Affordable Care Act (ACA) in the United States have seen a growth in the number of individuals who fall in the assistance gap, defined as having incomes above the Medicaid eligibility limit (\u226544% of the federal poverty level) but below the lower limit (&lt;100%) to be eligible for tax credits for premium subsidies or cost-sharing reductions in the marketplace. The purpose of this article is to present findings from a secondary data analysis examining the characteristics of those who fell in the assistance gap ( n\u2009=\u2009166) in Missouri, a Medicaid nonexpansion state, by comparing them with those who did not fall in the assistance gap ( n\u2009=\u2009157). Participants completed online demographic questionnaires and self-reported measures of health and insurance status, health literacy, numeracy, and health insurance literacy. A select group completed a 1-year follow-up survey about health insurance enrollment and health care utilization. Compared with the nonassistance gap group, individuals in the assistance gap were more likely to have lower levels of education, have at least one chronic condition, be uninsured at baseline, and be seeking health care coverage for additional dependents. Individuals in the assistance gap had significantly lower annual incomes and higher annual premiums when compared with the nonassistance gap group and were less likely to be insured through the marketplace or other private insurance at the 1-year follow-up. Findings provide several practice and policy implications for expanding health insurance coverage, reducing costs, and improving access to care for underserved populations.<\/jats:p>","DOI":"10.1177\/1527154418759312","type":"journal-article","created":{"date-parts":[[2018,2,20]],"date-time":"2018-02-20T11:30:11Z","timestamp":1519126211000},"page":"206-214","update-policy":"https:\/\/doi.org\/10.1177\/sage-journals-update-policy","source":"Crossref","is-referenced-by-count":4,"title":["Exploring Characteristics and Health Care Utilization Trends Among Individuals Who Fall in the Health Insurance Assistance Gap in a Medicaid Nonexpansion State"],"prefix":"10.1177","volume":"18","author":[{"given":"Jean","family":"Edward","sequence":"first","affiliation":[{"name":"Center for Health Services Research, University of Kentucky, Lexington, KY, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Nageen","family":"Mir","sequence":"additional","affiliation":[{"name":"Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Denise","family":"Monti","sequence":"additional","affiliation":[{"name":"Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Enbal","family":"Shacham","sequence":"additional","affiliation":[{"name":"College for Public Health and Social Justice, Department of Behavioral Sciences and Health Education, Saint Louis University, MO, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Mary C.","family":"Politi","sequence":"additional","affiliation":[{"name":"Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"179","published-online":{"date-parts":[[2018,2,20]]},"reference":[{"key":"bibr1-1527154418759312","unstructured":"Antonisse, L., Garfield, R., Rudowitz, R. & Artiga, S. (2017).\n                      The effects of Medicaid expansion under the ACA: Updated findings from a literature review\n                      . Retrieved from https:\/\/www.kff.org\/medicaid\/issue-brief\/the-effects-of-medicaid-expansion-under-the-aca-updated-findings-from-a-literature-review-september-2017\/."},{"key":"bibr2-1527154418759312","unstructured":"Artiga, S., Damico, A. & Garfield, R. (2015).\n                      The impact of the coverage gap for adults in states not expanding Medicaid by race and ethnicity.\n                      Retrieved from https:\/\/www.kff.org\/disparities-policy\/issue-brief\/the-impact-of-the-coverage-gap-in-states-not-expanding-medicaid-by-race-and-ethnicity\/."},{"key":"bibr3-1527154418759312","unstructured":"Automated Health Systems. (2018).\n                      Gateway to better health\n                      . Retrieved from https:\/\/stlgbh.com\/."},{"key":"bibr4-1527154418759312","doi-asserted-by":"publisher","DOI":"10.1377\/hlthaff.2017.0004"},{"key":"bibr5-1527154418759312","unstructured":"Blumberg, L. J., Holahan, J. & Buettgens, M. (2015).\n                      How much do marketplace and other nongroup enrollees spend on health care relative to their incomes.\n                      Retrieved from https:\/\/www.urban.org\/sites\/default\/files\/publication\/76446\/2000559-How-Much-Do-Marketplace-and-Other-Nongroup-Enrollees-Spend-on-Health-Care-Relative-to-Their-Incomes.pdf."},{"key":"bibr6-1527154418759312","unstructured":"Buettgens, M. & Kenney, G. M. (2016).\n                      What if more states expanded Medicaid in 2017? Changes in eligibility, enrollment and the uninsured.\n                      Retrieved from https:\/\/www.urban.org\/sites\/default\/files\/publication\/82786\/2000866-What-if-More-States-Expanded-Medicaid-in-2017-Changes-in-Eligibility-Enrollment-and-the-Uninsured.pdf."},{"key":"bibr7-1527154418759312","doi-asserted-by":"crossref","unstructured":"Camilleri, S. (2017). The ACA Medicaid expansion, disproportionate share hospitals, and uncompensated care.\n                      Health Services Research\n                      . doi:10.1111\/1475-6773.12702.","DOI":"10.1111\/1475-6773.12702"},{"key":"bibr8-1527154418759312","unstructured":"Chang, D. (2015). Relying on healthcare safety net: Choosing between dinner and a medical test.\n                      Kaiser Health News.\n                      Retrieved from http:\/\/khn.org\/news\/relying-on-the-health-care-safety-net\/."},{"key":"bibr9-1527154418759312","unstructured":"Dickman, S., Himmelstein, D., McCormick, D. & Woolhandler, S. (2014). Opting out of Medicaid expansion: The health and financial impacts.\n                      Health Affairs Blog.\n                      Retrieved from http:\/\/www.healthaffairs.org\/do\/10.1377\/hblog20140130.036694\/full\/."},{"key":"bibr10-1527154418759312","unstructured":"Garfield, R. & Damico, A. (2016).\n                      The coverage gap: Uninsured poor adults in states that do not expand Medicaid.\n                      Retrieved from https:\/\/www.kff.org\/uninsured\/issue-brief\/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid\/."},{"key":"bibr11-1527154418759312","doi-asserted-by":"publisher","DOI":"10.1377\/hlthaff.2014.1058"},{"key":"bibr12-1527154418759312","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMp1208219"},{"key":"bibr13-1527154418759312","unstructured":"Kaiser Family Foundation. (2016).\n                      Explaining health care reform: Questions about health insurance subsidies\n                      . Retrieved from https:\/\/www.kff.org\/health-reform\/issue-brief\/explaining-health-care-reform-questions-about-health\/."},{"key":"bibr14-1527154418759312","unstructured":"Kaiser Family Foundation. (2017).\n                      Health insurance coverage of the total population\n                      . Retrieved from http:\/\/kff.org\/other\/state-indicator\/total-population\/?currentTimeframe=0s."},{"key":"bibr15-1527154418759312","doi-asserted-by":"publisher","DOI":"10.1177\/0272989X0102100105"},{"key":"bibr16-1527154418759312","doi-asserted-by":"publisher","DOI":"10.1186\/1471-2296-7-21"},{"key":"bibr17-1527154418759312","unstructured":"Norris, L. (2017).\n                      What is the Medicaid \u2018coverage gap\u2019 and who does it affect?\n                      Retrieved from https:\/\/www.healthinsurance.org\/faqs\/what-is-the-medicaid-coverage-gap-and-who-does-it-affect\/."},{"key":"bibr18-1527154418759312","doi-asserted-by":"publisher","DOI":"10.1080\/10810730.2014.936568"},{"key":"bibr19-1527154418759312","first-page":"1","volume":"1","author":"Politi M. 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Department of Health and Human Services","year":"2009"}],"container-title":["Policy, Politics, &amp; Nursing Practice"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/journals.sagepub.com\/doi\/pdf\/10.1177\/1527154418759312","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/journals.sagepub.com\/doi\/full-xml\/10.1177\/1527154418759312","content-type":"application\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/journals.sagepub.com\/doi\/pdf\/10.1177\/1527154418759312","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,5,2]],"date-time":"2026-05-02T05:48:02Z","timestamp":1777700882000},"score":1,"resource":{"primary":{"URL":"https:\/\/journals.sagepub.com\/doi\/10.1177\/1527154418759312"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2017,11]]},"references-count":24,"journal-issue":{"issue":"4","published-print":{"date-parts":[[2017,11]]}},"alternative-id":["10.1177\/1527154418759312"],"URL":"https:\/\/doi.org\/10.1177\/1527154418759312","relation":{},"ISSN":["1527-1544","1552-7468"],"issn-type":[{"value":"1527-1544","type":"print"},{"value":"1552-7468","type":"electronic"}],"subject":[],"published":{"date-parts":[[2017,11]]}}}